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ANTIBIOTICS AND CHEMOTHERAPY IN SINUSITIS
207
INTERNATIONAL
CONGRESS
DURING the week beginning on Monday, July 18, 1300 delegates, from forty nations, attended this conference in weather which gave them the opportunity of seeing London at its best. The delegates agreed that this meeting-the first since the war and the fourth since the original congress in 1928-proved to be the best organised and the most generally successful of the series. The ceremonies and discussions were held at King’s College in the Strand, and it was clear to each delegate as soon as he entered the college to register that his entertainment, his accommodation, and the conduct of the multitudinous items of the congress had been carefully planned. Mr. F. C. W. Capps, the general secretary, had been engaged on the detailed plans for two years, with the experienced help of the secretariat of the Royal College of Surgeons. Mr. W. A. Mill was financial secretary, Mr. G. H. Bateman academic secretary, Mr. F. C. Ormerod and Mr. C. P. Wilson scientific secretaries, and Mr. Myles L. Formby reception secretary. The chairman of the ladies’ committee was Mrs. V. E. Negus. The president, Mr. V. E. Negus, infused a happy spirit - of international friendliness into the
over
proceedings. The great hall of King’s College was crowded when the Duchess of Kent arrived to declare the congress open. She hoped that it would prove important not only as a forum for the exchange of medical ideas but also as a means of furthering international understanding. Prof. F. R. Nager,, speaking for the visitors from over-
expressed the gratitude which they all felt at the lead which Great Britain was giving the world in its search for peace.
seas,
The profusion of the fare provided made it impossible for. the delegates to attend every session. They were constantly faced with the need to decide where they should spend any given moment-for instance, there were generally no fewer than four academic sessions in progress at one time, and beyond these there were the attractions of demonstrations, films, exhibitions, visits to hospitals, and sight-seeing tours. Exhibitions of surgical instruments, of hearing-aids, of medical books, and to illustrate the history of otolaryngology were well patronised. Despite the journey to the fourth floor that it entailed, the collection of anatomical and pathological specimens attracted many visitors. On this floor too were to be seen Dr. Gray’s remarkable specimens illustrating the anatomy of the inner ear, and Mr. Negus’s unique collection of specimens demonstrating the comparative anatomy of the larynx. The exhibitions of medical films were particularly not only because of their individual excellence but also because they circumvented the curse of Babel. If " The function of the ear in health and disease," produced by Dr. H. G. Kobrak, of Chicago, and the " Slow motion film of movements of vocal cords " produced by the Edison Bell Co. are representative ofthe general level of achievement, one can say that the medical film is among the most noteworthy of the recent advances in medical teaching.
popular, perhaps
Some idea of the lavish social programme may be the following diary : Monday, President’s the Gardens of the Zoological Society of London. Tuesday, banquet at the Dorchester Hotel. Wednesday, reception by His Majesty’s Government. Thursday, receptions by the London and at the Royal Society of Medicine. Council County Friday, reception at the Royal College of Surgeons of
gathered from Reception in
England.
OF
OTOLARYNGOLOGY
ANTIBIOTICS AND CHEMOTHERAPY IN SINUSITIS
The proceedings began with a film made by Dr. PAUL HOLINGER (Chicago) illustrating his technique of motion photography in colour of the structures of the ear, nose, and throat in health and disease. The perfection of the photography was new to many of the European delegates. After.lunch the academic programme began in earnest, with papers by two British pioneers in the study of Sir ALEXANDER FLEMING, F.R.S., antibacterial drugs. gave an account of the ways in which the blood-level of penicillin could be maintained throughout the twentyfour hours. He referred to the more recent antibiotics - streptomycin, aureomycin, and chloromycetin-and to the effects which might be expected from a mixture of these substances. The organisms causing sinusitis were much the same as those responsible for other respiratory infections, and we had antibiotics to deal with all of them ; the problem was to get the. drug to the seat of the infection.
Sir LIONEL WHITBY asked: " Have the sulphonamide any place in treatment now that we are armed with His answer was " Yes," first on the score antibiotics’? " of their availability and secondly because of their action on He indicated the the gram-negative bacteria. conditions under which these drugs could be expected to exert their maximum effect, and stressed the importance, in otolaryngology, of free drainage of secretions. Prof. CARLOS LARROUDE (Lisbon) also emphasised the need for drainage of pus whenever it was present. The real value of these therapeutic agents lay in the treatment of acute rather than chronic disease. The symptoms of acute sinusitis and its complications were greatly modified where these drugs were used, and this opened up a new field for clinical study. Subsequent speakers amplified Sir Alexander Fleming’s remarks on the uselessness of administering penicillin if local factors were preventing its concentration at the site of the disease. Prof. J. J. BARROILHET (Santiago) felt that this was never achieved by the use of aerosols, and Mr. E. G. COLLiNS described his experience with indwelling ureteric catheters as a means of applying penicillin to the maxillary antra of children for the relief of subacute antritis. Two points stand out from this afternoon’s proceedings : (1) penicillin and other antibacterial drugs do not replace, but are a valuable adjunct to, surgery in the treatment of nasal sinusitis and its complications ; and (2) these drugs are useless unless they reach the infected tissue in sufficient concentration.
drugs
AURAL VERTIGO
Prof. F. R. NAGER (Zurich), in opening this session, dealt principally with the question whether labyrinthine hydrops in the absence of inflammation could be regarded as the fundamental lesion in Meniere’s disease. He showed some beautiful microscopical sections through the labyrinth from a variety of sources, illustrating the frequency with which these findings were present. In his opinion in two-thirds of all cases of Meniere’s disease a non-inflammatory labyrinthine hydrops could be demonstrated. It was a great disappointment to the several hundred delegates present that Prof. C. NYLEN (Uppsala) was too ill to attend. His paper was read by Dr. G. HERBERTS (Uppsala). Over many years Professor Nylen’s experience had led him to advocate conservative treatment in most cases of aural vertigo, and 70% of 180 patients recently followed up had been so treated. He considered
208 it necessary to investigate each case carefully, to excludt a central neur.ological lesion. A proportion he considered to be circulatory and others allergic in origin. In suitable cases his suggested treatment included a modification of Day’s operative procedure. Dr. W. J. MCNALLY (Montreal) reviewed a series ol 200 cases, treated by him over ten years. His most important conclusion was that spontaneous remission with an average duration of four years was common in Ménière’s disease. This neçessitated the greatest It was not caution in assessing results of treatment. wise to speak of cure until a case had been free from symptoms for five years. Failure to appreciate this fact might lead to the most misleading interpretation Like Professor of the value of this or that remedy. should be reserved for the he held that surgery Nylén very few selected cases. He wondered if, in destroying the labyrinth, we were not sometimes interfering with Nature’s danger signal. It was clear that Dr. McNally’s paper had had its effect on those who took part in the discussion. For instance, Mr. GARNETT PASSE was at pains to interpret his results after upper dorsal sympathectomy as being symptomatic improvement rather than cure. Dr. C.-A. HAMBERGER gave an account of his work on guineapigs, in which he had attempted to identify the lesion produced by streptomycin. He had found lesions both in the vestibular nuclei and in the vestibular ganglion, and he wondered if the former were secondary to the latter. Prof. G. PORTMANN (Bordeaux) urged that a place remained for decompression of the labyrinth by removal of the saccus endolymphaticus. Mr. T. E. CAWTHORNE described the technique of his operation-in which he avulses the membranous horizontal canal of - the his recent results. labyrinth. He A great impression was undoubtedly made by Dr. McNally, and the audience went away determined to be more cautious in future in the interpretation of their results.
(Stockholm)
also’ analysed
NON-MALIGNANT STRICTURES OF THE THORACIC ŒSOPHAGUS
Dr. GABRIEL TUCKER (Philadelphia) concentrated on strictures of three ætiologies—the congenital, the short oesophagus with intrathoracic stomach, and the stricture following caustic burns. With the aid of an excellent colour film, he demonstrated the technique of retrograde dilatation. The patients, two of whom were children, were seen swallowing a length of string, the end of which was later recovered from the stomach through a gastrostomy by the aid of a sucker. Bougies attached to this string were then drawn up the oesophagus. Prof. J. TERRACOL (Montpellier) described the frequency with which caustic burns of the oesophagus were encountered in France. He indicated his treatment, which appeared to agree with that of the previous
speaker.
.
Dr. P. G. GERLINGS (Amsterdam) also remarked on the common occurrence of caustic burns, which had become increasingly frequent during the war. He stressed the vital importance of skill and judgment born of long experience in the treatment of these cases, and advocated transthoracic resection of the stricture where bouginage is impracticable. Speaking of the treatment of short oesophagus and associated stricture; he dwelt on the insufficiency of the cardiac valve and the regurgitation of gastric juices as aetiological factors. The PRESIDENT paid tribute to the hydrostatic bag as an invaluable instrument in achieving dilatation of strictures of the lower oesophagus. He pointed out that the credit for introducing this to the medical world should go to Dr. Tucker.
In the general discussion various speakers drew attention to the frequency of caustic burns of the cesophagus, which are apparently much more common Dr. C. L. JACKSON abroad than in Great Britain. (Philadelphia) referred to the legislation which had been necessary in an attempt to reduce the number of burns due to children drinking caustics by accident. Dr. P. HOLINGER (Chicago) drew attention to the increasing number of postoperative strictures. The more aggressive surgery of the oesophagus, as practised today, was presenting endoscopists with a new problem, that of annular stricture at the site of oesophagogastrostomy. The consensus of opinion on the value of an indwelling string in the treatment of severe strictures was crystallised by Dr. L. H. CLERF (Philadelphia). This point and the importance of gentleness and perseverance in treatment were the main items which the observer stored in his memory. -
*
*
*
In addition to these combined sessions, other sessions held throughout the week under the chairmanship of the vice-presidents : Mr. KENNEDY HUNTER, Mr. G. EWART MARTIN, Mr. W. M. MOLLISON, Mr. R. D. OwEN, and Mr. A. J. M. WRIGHT. On leaving the congress, an Italian surgeon was overheard to make a remark which will serve as an epitome of the spirit which animated all the proceedings : " Politicians create the barriers between nations ; science throws them’ down." were
Medicine and the Law Duration of
Pregnancy 360-day baby, if it may so
THE case of the be described, is to go to the House of Lords. The husband’s evidence was that he was serving overseas from June 17, 1944, to February, 1946, when he was demobilised. He had leave in August, 1945, which he spent with his wife. A child was born in August, 1946. In the Court of Appeal Lord Justice Denning observed that the date of the birth meant, in the ordinary course of events, that the child was conceived in November, 1945. In his opinion the suggestion that the period of gestation was 360 days could be called fantastic. Once it was proved that the husband was not in England at the time, there was an irresistible inference that the child was conceived in adultery. Lord Justice Denning was prepared to grant the husband a decree nisi in his application for a divorce, but his two colleagues took a different view. Lord Justice Bucknill thought that the scientific evidence had better be re-examined at a new trial ; there was no clear scientific evidence on the point at issue. The trial court must balance the probabilities one against another and not regard it as a question of law. Lord Justice Asquith concurred with Lord Justice Bucknill. In view of the want of unanimity in the Court of Appeal leave was given for the parties to appeal to the House of Lords. Not many days ago the Court of Appeal refused an application by the husband to call fresh evidence. The ground of refusal was that the proposed evidence could perfectly well have been given at the original trial. Now the Court of Appeal has ordered (subject, of course to any review of its decision by. the House of Lords) that there must be a new trial when it will be open to the parties to call the best medical evidence available. There have been, as Lord Justice Bucknill remarked, cases of unsuccessful allegations of misconduct when babies had been born 346 and 349 days after the last opportunity for marital intercourse. Counsel for the husband has argued that the courts will have to draw the line somewhere. ’
INTERNATIONAL
CONGRESS
DURING the week beginning on Monday, July 18, 1300 delegates, from forty nations, attended this conference in weather which gave them the opportunity of seeing London at its best. The delegates agreed that this meeting-the first since the war and the fourth since the original congress in 1928-proved to be the best organised and the most generally successful of the series. The ceremonies and discussions were held at King’s College in the Strand, and it was clear to each delegate as soon as he entered the college to register that his entertainment, his accommodation, and the conduct of the multitudinous items of the congress had been carefully planned. Mr. F. C. W. Capps, the general secretary, had been engaged on the detailed plans for two years, with the experienced help of the secretariat of the Royal College of Surgeons. Mr. W. A. Mill was financial secretary, Mr. G. H. Bateman academic secretary, Mr. F. C. Ormerod and Mr. C. P. Wilson scientific secretaries, and Mr. Myles L. Formby reception secretary. The chairman of the ladies’ committee was Mrs. V. E. Negus. The president, Mr. V. E. Negus, infused a happy spirit - of international friendliness into the
over
proceedings. The great hall of King’s College was crowded when the Duchess of Kent arrived to declare the congress open. She hoped that it would prove important not only as a forum for the exchange of medical ideas but also as a means of furthering international understanding. Prof. F. R. Nager,, speaking for the visitors from over-
expressed the gratitude which they all felt at the lead which Great Britain was giving the world in its search for peace.
seas,
The profusion of the fare provided made it impossible for. the delegates to attend every session. They were constantly faced with the need to decide where they should spend any given moment-for instance, there were generally no fewer than four academic sessions in progress at one time, and beyond these there were the attractions of demonstrations, films, exhibitions, visits to hospitals, and sight-seeing tours. Exhibitions of surgical instruments, of hearing-aids, of medical books, and to illustrate the history of otolaryngology were well patronised. Despite the journey to the fourth floor that it entailed, the collection of anatomical and pathological specimens attracted many visitors. On this floor too were to be seen Dr. Gray’s remarkable specimens illustrating the anatomy of the inner ear, and Mr. Negus’s unique collection of specimens demonstrating the comparative anatomy of the larynx. The exhibitions of medical films were particularly not only because of their individual excellence but also because they circumvented the curse of Babel. If " The function of the ear in health and disease," produced by Dr. H. G. Kobrak, of Chicago, and the " Slow motion film of movements of vocal cords " produced by the Edison Bell Co. are representative ofthe general level of achievement, one can say that the medical film is among the most noteworthy of the recent advances in medical teaching.
popular, perhaps
Some idea of the lavish social programme may be the following diary : Monday, President’s the Gardens of the Zoological Society of London. Tuesday, banquet at the Dorchester Hotel. Wednesday, reception by His Majesty’s Government. Thursday, receptions by the London and at the Royal Society of Medicine. Council County Friday, reception at the Royal College of Surgeons of
gathered from Reception in
England.
OF
OTOLARYNGOLOGY
ANTIBIOTICS AND CHEMOTHERAPY IN SINUSITIS
The proceedings began with a film made by Dr. PAUL HOLINGER (Chicago) illustrating his technique of motion photography in colour of the structures of the ear, nose, and throat in health and disease. The perfection of the photography was new to many of the European delegates. After.lunch the academic programme began in earnest, with papers by two British pioneers in the study of Sir ALEXANDER FLEMING, F.R.S., antibacterial drugs. gave an account of the ways in which the blood-level of penicillin could be maintained throughout the twentyfour hours. He referred to the more recent antibiotics - streptomycin, aureomycin, and chloromycetin-and to the effects which might be expected from a mixture of these substances. The organisms causing sinusitis were much the same as those responsible for other respiratory infections, and we had antibiotics to deal with all of them ; the problem was to get the. drug to the seat of the infection.
Sir LIONEL WHITBY asked: " Have the sulphonamide any place in treatment now that we are armed with His answer was " Yes," first on the score antibiotics’? " of their availability and secondly because of their action on He indicated the the gram-negative bacteria. conditions under which these drugs could be expected to exert their maximum effect, and stressed the importance, in otolaryngology, of free drainage of secretions. Prof. CARLOS LARROUDE (Lisbon) also emphasised the need for drainage of pus whenever it was present. The real value of these therapeutic agents lay in the treatment of acute rather than chronic disease. The symptoms of acute sinusitis and its complications were greatly modified where these drugs were used, and this opened up a new field for clinical study. Subsequent speakers amplified Sir Alexander Fleming’s remarks on the uselessness of administering penicillin if local factors were preventing its concentration at the site of the disease. Prof. J. J. BARROILHET (Santiago) felt that this was never achieved by the use of aerosols, and Mr. E. G. COLLiNS described his experience with indwelling ureteric catheters as a means of applying penicillin to the maxillary antra of children for the relief of subacute antritis. Two points stand out from this afternoon’s proceedings : (1) penicillin and other antibacterial drugs do not replace, but are a valuable adjunct to, surgery in the treatment of nasal sinusitis and its complications ; and (2) these drugs are useless unless they reach the infected tissue in sufficient concentration.
drugs
AURAL VERTIGO
Prof. F. R. NAGER (Zurich), in opening this session, dealt principally with the question whether labyrinthine hydrops in the absence of inflammation could be regarded as the fundamental lesion in Meniere’s disease. He showed some beautiful microscopical sections through the labyrinth from a variety of sources, illustrating the frequency with which these findings were present. In his opinion in two-thirds of all cases of Meniere’s disease a non-inflammatory labyrinthine hydrops could be demonstrated. It was a great disappointment to the several hundred delegates present that Prof. C. NYLEN (Uppsala) was too ill to attend. His paper was read by Dr. G. HERBERTS (Uppsala). Over many years Professor Nylen’s experience had led him to advocate conservative treatment in most cases of aural vertigo, and 70% of 180 patients recently followed up had been so treated. He considered
208 it necessary to investigate each case carefully, to excludt a central neur.ological lesion. A proportion he considered to be circulatory and others allergic in origin. In suitable cases his suggested treatment included a modification of Day’s operative procedure. Dr. W. J. MCNALLY (Montreal) reviewed a series ol 200 cases, treated by him over ten years. His most important conclusion was that spontaneous remission with an average duration of four years was common in Ménière’s disease. This neçessitated the greatest It was not caution in assessing results of treatment. wise to speak of cure until a case had been free from symptoms for five years. Failure to appreciate this fact might lead to the most misleading interpretation Like Professor of the value of this or that remedy. should be reserved for the he held that surgery Nylén very few selected cases. He wondered if, in destroying the labyrinth, we were not sometimes interfering with Nature’s danger signal. It was clear that Dr. McNally’s paper had had its effect on those who took part in the discussion. For instance, Mr. GARNETT PASSE was at pains to interpret his results after upper dorsal sympathectomy as being symptomatic improvement rather than cure. Dr. C.-A. HAMBERGER gave an account of his work on guineapigs, in which he had attempted to identify the lesion produced by streptomycin. He had found lesions both in the vestibular nuclei and in the vestibular ganglion, and he wondered if the former were secondary to the latter. Prof. G. PORTMANN (Bordeaux) urged that a place remained for decompression of the labyrinth by removal of the saccus endolymphaticus. Mr. T. E. CAWTHORNE described the technique of his operation-in which he avulses the membranous horizontal canal of - the his recent results. labyrinth. He A great impression was undoubtedly made by Dr. McNally, and the audience went away determined to be more cautious in future in the interpretation of their results.
(Stockholm)
also’ analysed
NON-MALIGNANT STRICTURES OF THE THORACIC ŒSOPHAGUS
Dr. GABRIEL TUCKER (Philadelphia) concentrated on strictures of three ætiologies—the congenital, the short oesophagus with intrathoracic stomach, and the stricture following caustic burns. With the aid of an excellent colour film, he demonstrated the technique of retrograde dilatation. The patients, two of whom were children, were seen swallowing a length of string, the end of which was later recovered from the stomach through a gastrostomy by the aid of a sucker. Bougies attached to this string were then drawn up the oesophagus. Prof. J. TERRACOL (Montpellier) described the frequency with which caustic burns of the oesophagus were encountered in France. He indicated his treatment, which appeared to agree with that of the previous
speaker.
.
Dr. P. G. GERLINGS (Amsterdam) also remarked on the common occurrence of caustic burns, which had become increasingly frequent during the war. He stressed the vital importance of skill and judgment born of long experience in the treatment of these cases, and advocated transthoracic resection of the stricture where bouginage is impracticable. Speaking of the treatment of short oesophagus and associated stricture; he dwelt on the insufficiency of the cardiac valve and the regurgitation of gastric juices as aetiological factors. The PRESIDENT paid tribute to the hydrostatic bag as an invaluable instrument in achieving dilatation of strictures of the lower oesophagus. He pointed out that the credit for introducing this to the medical world should go to Dr. Tucker.
In the general discussion various speakers drew attention to the frequency of caustic burns of the cesophagus, which are apparently much more common Dr. C. L. JACKSON abroad than in Great Britain. (Philadelphia) referred to the legislation which had been necessary in an attempt to reduce the number of burns due to children drinking caustics by accident. Dr. P. HOLINGER (Chicago) drew attention to the increasing number of postoperative strictures. The more aggressive surgery of the oesophagus, as practised today, was presenting endoscopists with a new problem, that of annular stricture at the site of oesophagogastrostomy. The consensus of opinion on the value of an indwelling string in the treatment of severe strictures was crystallised by Dr. L. H. CLERF (Philadelphia). This point and the importance of gentleness and perseverance in treatment were the main items which the observer stored in his memory. -
*
*
*
In addition to these combined sessions, other sessions held throughout the week under the chairmanship of the vice-presidents : Mr. KENNEDY HUNTER, Mr. G. EWART MARTIN, Mr. W. M. MOLLISON, Mr. R. D. OwEN, and Mr. A. J. M. WRIGHT. On leaving the congress, an Italian surgeon was overheard to make a remark which will serve as an epitome of the spirit which animated all the proceedings : " Politicians create the barriers between nations ; science throws them’ down." were
Medicine and the Law Duration of
Pregnancy 360-day baby, if it may so
THE case of the be described, is to go to the House of Lords. The husband’s evidence was that he was serving overseas from June 17, 1944, to February, 1946, when he was demobilised. He had leave in August, 1945, which he spent with his wife. A child was born in August, 1946. In the Court of Appeal Lord Justice Denning observed that the date of the birth meant, in the ordinary course of events, that the child was conceived in November, 1945. In his opinion the suggestion that the period of gestation was 360 days could be called fantastic. Once it was proved that the husband was not in England at the time, there was an irresistible inference that the child was conceived in adultery. Lord Justice Denning was prepared to grant the husband a decree nisi in his application for a divorce, but his two colleagues took a different view. Lord Justice Bucknill thought that the scientific evidence had better be re-examined at a new trial ; there was no clear scientific evidence on the point at issue. The trial court must balance the probabilities one against another and not regard it as a question of law. Lord Justice Asquith concurred with Lord Justice Bucknill. In view of the want of unanimity in the Court of Appeal leave was given for the parties to appeal to the House of Lords. Not many days ago the Court of Appeal refused an application by the husband to call fresh evidence. The ground of refusal was that the proposed evidence could perfectly well have been given at the original trial. Now the Court of Appeal has ordered (subject, of course to any review of its decision by. the House of Lords) that there must be a new trial when it will be open to the parties to call the best medical evidence available. There have been, as Lord Justice Bucknill remarked, cases of unsuccessful allegations of misconduct when babies had been born 346 and 349 days after the last opportunity for marital intercourse. Counsel for the husband has argued that the courts will have to draw the line somewhere. ’